Proton Facility Economics: Single-Room Centers

ObjectiveWe have previously described the central nature of simple cases for financial feasibility of proton beam therapy centers—especially four- to five-room centers. In the 5 years since that publication, such construction has slowed drastically, and smaller, single-room projects are in vogue. We now seek to show under what circumstances a single-room system is optimally financially viable.Materials and MethodsA “standard” construction cost and debt for a single gantry system of $40 million was presumed, with 75% of the construction funded through standard 20-year financing. We then modeled a statistical analysis, deriving the optimal case mix required daily to cover construction and debt service costs.ResultsWe previously published that a single gantry treating only complex patients would need to apply 85% of its treatment slots simply to service debt, though it would cover its debt treating 4 hours of simple patients. As the business model has changed, debt maintenance, profit and operational costs have somewhat reduced the business case for adding a large number of simple patients. Debt maintenance is possible with as little as 13% of daily patients for a 40% Medicare case mix, but these numbers are critically sensitive to continued patient throughput.ConclusionsEven in a single-room system, reducing overall debt, using tax-exempt financing, and having a case load emphasizing simple, private payer patients is paramount to fiscal health of the facility. Unused capacity is a huge risk if insufficient patients are available.     

When to do surgical resection for atypical breast lesions: Results of a prospective cohort of 518 lesions

AimThere is no consensual indication for surgical resection after diagnosis on per-cutaneous biopsy of borderline breast lesions (B3). We evaluate under-evaluation rate of per-cutaneous biopsy and predictive factors of under-evaluation. We analyze accuracy of reported decision-making tools.MethodsWe conduct a prospective multicentric study including, atypic-ductal hyperplasia (ADH), atypic-lobular hyperplasia (ALH), atypic-cylindro-cubic metaplasia (FEA), papilloma, radial scars (RS) and phyllod tumors. When several B3 lesions were associated, the more severe lesion was used to classify the lesion. We determined breast cancers (BC) rate and histologic type.Among 478 patients, 518 B3 lesions were studied: 15.1% (78) FEA, 48.6% (252) ADH, 16.8% (n = 87) ALH, 5.4% (n = 28) RS, 12% (n = 62) papilloma, 0.8% (n = 4) phyllod tumors and 0,8% (n = 4) with a suspicious low grade DCIS. More than 1 lesion was identified in 31.9% (165) of cases.A surgical resection was performed for 86.3% (447/518) lesions. Significant factors of surgical resection were: residual micro-calcification after biopsy (OR: 2.7) and type of B3 lesion.ResultsOverall BC rate was 15.3% (68/445) with 79.4% (54) in-situ carcinomas. According to B3 lesions, BC rates were 12.9% for FEA, 20% for ADH, 11.6% for ALH, 3.7% for RS, 8.8% for papilloma and 25% for suspicious in-situ carcinoma.A score has been calculated and patients were distributed in 3 groups. Patient's rates without BC were respectively: 100%, 80.4% and 80.6% (p = 0.029).ConclusionIn conclusion, it could be suggested to avoided complementary surgical resection in case of good radio-pathologic concordance and low probability of BC.